Defending Human Health: A Thankless Job
Originally posted on: Michigan Science Writers
Growing up, I was an avid soccer player. But, I never wanted the glory of being a team’s leading scorer. Defense was my home. That is until I scored my first goal. I was elated, but quickly realized that I had never in my time on defense received anywhere near the validation that I had for that goal. I could save goals or shut down the other team’s star player, but that usually went unnoticed. If anything, I was typically criticized for something I didn’t do more often than I was praised for something I did. This experience taught me something important – defense is a thankless job.
Interestingly, the same pattern that I saw in my soccer experience happens all the time with public health.
Public health officials at the Center for Disease Control and Prevention (CDC), regional and local public health offices, and organizations like the World Health Organization (WHO) are tasked with an enormous responsibility. Their job is to ensure the health and well-being of the human population against occupational, environmental, and infectious disease hazards. And they’re often asked to do so with insufficient funds and personnel. Just as I had to anticipate and evaluate the opposing team’s offense in soccer, public health officials must assess threats and predict problems, while simultaneously being wary of over-estimating a threat for fear of being painted as irresponsible or rash.
TAKE 2009'S SWINE FLU EPIDEMIC...
When 2009’s H1N1 flu strain was identified, concern among public health officials revolved around its resemblance to the 1918 strain of influenza virus, which decimated the human population after World War I. Additionally, the 2009 H1N1 strain targeted a different population than normal, with the vast majority of the hospitalizations and deaths occurring in adults younger than age 65, rather than young children and the elderly.
Health agencies worldwide mobilized, issuing statements about an “imminent” pandemic, recommending that countries activate “pandemic preparedness plans”, and warning against travel to certain countries. The result was media sensationalism. Swine flu was called a “killer virus”, and countries reacted in questionable ways – including including quarantining certain ethnicities and slaughtering pigs. In some places, the scared public ran around in face masks, while in others instances they pilfered TamiFlu antivirals for protection.
Ultimately, the 2009 pandemic resolved with far fewer deaths than expected. “We did a lot of things right,” Dr. Andrew T. Pavia, chairman of the pandemic flu task force of the Infectious Diseases Society of America, told The New York Times. Treatment was provided only to at-risk patients (instead of a mass vaccination program fiasco like in response to a 1976 pandemic), healthcare resources were managed effectively, and the CDC did their best to inform and manage misinformation. Regardless, many people still pointed fingers at public health officials for over-hyping the danger of the H1N1 flu. A Washington Post article claimed that “global hysteria over swine flu reminds [us] that the cure is often worse than the disease.” Some politicians publicly stated that “there hasn’t been that much danger”. Regardless, health officials believe that the response to swine flu, though seemingly overkill, was needed to combat a potential threat. “It’s the classic problem in public health, trying to prove a negative,” Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations, told The New York Times in the wake of the epidemic. “If, after an intervention, nothing happens, then everybody says, ‘What was the big deal?'”
In the 2009 swine flu outbreak, it seemed as if you’re damned if you do, and damned if you don’t. Despite what many deemed effective management, public health officials were still critiqued and scolded. The situation could have been much worse, as policymakers and the public would soon find out.
THE 2014 EBOLA EPIDEMIC
Before 2014, Ebola had primarily been a horror-story illness, serving as an antagonist in films like Outbreak. However, in 2014 and 2015, the virus ripped through West Africa in the single largest Ebola epidemic in history, with over 27,000 cases and more than 11,000 deaths. The World Health Organization (WHO) was widely criticized for being “unable to meet its responsibility.” Accusations of mismanagement spread to United States health systems when the first Ebola case on U.S. soil was diagnosed at Texas Health Presbyterian Hospital, resulting in transmission to two nurses. Fingers were pointed first at the hospital, then at the health care system and the CDC. But were those evaluations fair?
The “CDC has in practice very limited real authority”, said Dr. J. Stephen Morrison, senior VP at the Center for Strategic and International Studies. While the CDC is seen as the end-all-be-all of public health in the U.S., the advice that the CDC provides is just that. Advice. The CDC has no regulatory power over state and local governments, who may not even have the infrastructure or funding to put such guidelines into place.
In the case of Ebola, the public and the media largely chose to see the things that health organizations and workers did wrong. However, health organizations were not credited for the things they did right. Dr. Emily Martin*, Assistant Professor in Epidemiology at the University of Michigan, emphasized that “in areas where Ebola hit, it was really public health at its best. It wasn’t fancy technology, but contact tracing and epidemiology at its finest.” However, the great work done by first responders on the ground in west Africa went largely ignored.
APPLYING THESE LESSONS TO ZIKA...
On the heels of the Ebola outbreak came Zika virus. Primarily found in Africa and Southeast Asia, Zika was not considered particularly dangerous since infected individuals developed mild to no symptoms. Then, in late 2015, after an epidemic in Brazil, the virus started to draw attention when clusters of babies were born with microcephaly, a condition characterized by abnormally small heads, brain damage, and Guillian-Barre syndrome. Guillian-Barre, an illness where the body’s immune system attacks its nervous system, sometimes resulting in paralysis, was also observed in adults following Zika infection. Zika virus has since been deemed a public health emergency of international concern (PHEIC), and recent reports from the CDC have confirmed that Zika does cause microcephaly.
With Zika virus following so soon after Ebola, the lessons learned by the public health community are being felt, such as the importance of recognizing the severity of public health threats early. Dr. Amesh Adalja, senior associate at the UPMC Center for Health Security agreed: “I think based on that, you’re seeing a much more proactive, earlier response to Zika from the WHO than we did during Ebola.”
Perhaps the most important lesson applied to the Zika response was the effective adaptation of public health communication, which was lacking in our Ebola response. Therefore, one of the biggest differences between the Ebola and Zika response has been how these uncertainties and changing healthcare protocols have been communicated. “Ebola was a very quickly evolving situation,” said Dr. Martin. “We didn’t have perfect information…Sometimes it’s not that there is neglect going on. It’s that the information and what we know about the disease is constantly changing. How do you respond when during the response your information is changing? What we understand about Zika virus changes day-to-day. Therefore, the advice that we give to people changes from day-to-day.” The Zika response seems to have a transparency that was lacking with Ebola, particularly regarding what we do and do not know about the disease.
Public health, epidemiology, and science as a whole are ever-evolving, with new discoveries daily, and new hypotheses and questions constantly being tested. It never ends. “It’s easy to say, ‘well, why didn’t they look that up before?’ Because you can’t look that up. The information is just not available”, said Dr. Martin.
The public health personnel who participated in these outbreaks weren’t intentionally being negligent, rash, or unintelligent in their decision making. They did what they could with what they had. Though mistakes were made and different actions could have been taken, we need to appreciate where public health workers are coming from, and the often insurmountable tasks they face. They must face them regardless of the situation, funding level, or disease.
These people spend their careers keeping us safe from all that is threatening our health. We owe them more than finger pointing and accusations. We owe them a thank you.
*Personal Interview with Dr. Emily Martin. 4 Apr. 2016.